Soft Tissue Distraction Research Articles

Investigating the role connective tissue fibroblasts play in the altered muscle anatomy associated with the limb abnormality, Radial Dysplasia.

Radial dysplasia (RD) is a congenital upper limb birth defect that presents with changes to the upper limb anatomy, including a shortened or absent radius, bowed ulna, thumb malformations, a radially deviated hand and a range of muscle and tendon malformations, including absent or abnormally shaped muscle bundles. Current treatments to address wrist instability caused by a shortened or absent radius frequently require an initial soft tissue distraction intervention followed by a wrist stabilisation procedure. Following these surgical interventions, however, recurrence of the wrist deviation remains a common, long-term problem following treatment. The impact of the abnormal soft connective tissue (muscle and tendon) anatomy on the clinical presentation of RD and the complications following surgery are not understood. To address this, we have examined the muscle, fascia and the fascial irregular connective tissue (ICT) fibroblasts found within soft connective tissues, from RD patients. We show that ICT fibroblasts isolated from RD patients are functionally abnormal when compared to the same cells isolated from control patients and secrete a relatively disordered extracellular matrix (ECM). Furthermore, we show that ICT fibroblast dysfunction is a unifying feature found in RD patients, even when the RD clinical presentation is caused by distinct genetic syndromes.

The unsolved problem of radial longitudinal dysplasia: how can we reliably prevent recurrence, preserve growth and optimize function?

Congenital radial longitudinal dysplasia remains an 'unsolved problem' in hand surgery. The challenges presented by the skeletal deficiency of the distal radius and soft tissue dysplasia of the severe radial longitudinal deficiency have been addressed by a number of techniques that aim to stabilize the position of the hand relative to the forearm and optimize forearm growth and hand function. Analysis of hand function and position in these children is difficult because of the abnormal 'wrist' mechanics, and the published results of the techniques used to date often lack a standardized approach and importantly the perception of function from the patient's perspective. The existing data is reviewed and compared with the results of cohorts from two major congenital upper limb centres. Soft tissue distraction prior to radialization or centralization may offer benefit in ulnar growth and forearm length but there is a need for further research into the long-term functional outcomes of the various techniques available to determine the optimal choice for these children.Level of evidence: V.

Management of Neglected Multiple Ligament Rupture of the Knee: A Case Report

Delayed or neglected multiple ligament injury of the knee is challenging or doctors and physiotherapists. We report on a 36-year-old army man who presented to the outpatient orthopaedic department with complaints of pain and deformity of his right knee and an inability to weight-bear on the right leg. The examination of the right knee revealed an unreduced posterior dislocation of the knee with instability in all planes and a limited range of motion (ROM) from 10° to 100°. Quadriceps wasting was noted. Roentgenograms revealed a posterior dislocation of the knee. Magnetic resonance imaging (MRI) showed complete rupture of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and the patellar tendon. A two-stage surgery was planned, involving soft tissue distraction with external fixation to restore the knee joint, followed by multiple ligament reconstruction. Three months after surgery, the patient could walk normally with ROM between 0° to 120°.

Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7-14-year Follow-up.

Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient– a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities.How to cite this article: Lahoti O, Abhishetty N, Shetty S. Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7–14-year Follow-up. Strategies Trauma Limb Reconstr 2021;16(2):96–101.

Neglected сlubfoot treated by Ilizarov and Ponseti methods

The Ponseti method has revolutionized clubfoot treatment. Though completely neglected clubfeet are now rare, partially or incompletely and improperly treated feet are not uncommon. Relapses after successful correction may occur due to non-compliance with bracing. In scarred soft tissues due to previous surgery, soft tissue distraction using external fixation helps achieve correction. The Ilizarov fixator permits us to follow the Ponseti protocol, using correction methods that may either be constrained or unconstrained by hinges. Applying force vectors perpendicular to the moment arm allows us to correct the еquinus without damaging the ankle joint. All of the above is possible when the talus is round. Full correction of the deformity is possible. However, longterm follow-up of these patients has revealed stiffness of the ankle setting and frequently with tibio-talar osteophytes anteriorly. They are probably a reaction to excessive pressure developed in the joint due to the tight soft tissues. Hence the author has now added a mild shortening of the tibia and fibula to reduce soft tissue tension, rather than resorting to further soft tissue releases through scarred tissues. This allows faster correction with the Ponseti-Ilizarov protocol and allows good ankle range of motion to persist.

Satisfying Clinical and Functional Results in 12 Apert Children Treated With Soft Tissue Distractor.

The complex syndactyly in Apert syndrome hands is challenging to operate. The synostosis and tightness of skin between third and fourth digits lead to severe coverage problems during ray release. A soft tissue distractor can simplify the release with the aim to keep all 10 fingers. A retrospective follow-up of 12 patients/24 hands, median age 8 years (6 to 17 y), 6 boys and 6 girls, operated between 2000 and 2013 was done from 2015 to 2016. The surgical management started with syndactyly release of the first and fourth web, and later of the second. The third stage was placing a soft tissue distractor on the third and fourth finger after osteotomy on the synostosis between them. Four weeks of distraction and 2 weeks of rest resulted in regenerated skin between the digits giving much better coverage of the released digits at time of separation 6 weeks later. Assessment of hand function, grip strength and completion of the Patient Reported Outcome Measure CHEQ was performed. Soft tissue coverage at the time of digit separation was considerably facilitated. We experienced 2 infections in 2 hands. In 18/24 hands median 2 (1 to 3) small full thickness skin grafts were needed, usually for coverage of the base of the digits. All wounds healed well. The children managed different practical tasks well, alternating between best functioning grip depending on the activity. According to CHEQ, the children did median 19 (13 to 27) activities independently and median 8 (2 to 15) nonindependently, of a total of 29. Peak strength values for 10/12 children were for the right hand median 17.8% (9.6% to 40.6%) of normative data and for left hand median 13.6% (2.4% to 20.5%) of normative data. Soft tissue distraction facilitates the treatment of acrocephalosyndactyly hands, giving 5-fingered hands. Apert children manage many activities independently but struggled with fine motor skills demanding strength. Level IV evidence.

Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases

BackgroundLarge post-traumatic tibial bone defects combined with soft tissue defects are a common orthopedic clinical problem associated with poor outcomes when treated using traditional surgical methods. The study was designed to investigate the safety and efficacy of trifocal bone transport (TFT) and soft-tissue transport with the Ilizarov technique for large posttraumatic tibial bone and soft tissue defects.MethodsWe retrospectively reviewed 31 patients with massive posttraumatic tibial bone and soft tissue defects from May 2009 to May 2016. All of the eligible patients were managed by TFT and soft-tissue transport. The median age was 33.4 years (range, 2–58 years). The mean defect of bone was 11.87 cm ± 2.78 cm (range, 8.2–18.2 cm) after radical resection performed by TFT. The soft tissue defects ranged from 7 cm × 8 cm to 24 cm × 12 cm. The observed results included bone union time, wound close time and true complications. The Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system was used to assess bone and functional results and postoperative complications were evaluated by Paley classification.ResultsThe mean duration of follow-up after frame removal was 32 months (range, 12–96 months). All cases achieved complete union in both the elongation sites and the docking sites, and eradication of infection. The mean bone transport time was 94.04 ± 23.33 days (range, 63.7–147 days). The mean external fixation time was 22.74 ± 6.82 months (range, 14–37 months), and the mean external fixation index (EFI) was 1.91 ± 0.3 months/cm (range, 1.2–2.5 months/cm). The bone results were excellent in 6 patients, good in 14 patients, fair in 8 patients and poor in 3 patients. The functional results were excellent in 8 patients, good in 15 patients, fair in 5 patients and poor in 3 patients. Conclusion: TFT, in conjunction with soft tissue transport technique, can give good results in most patients (in this article, good and excellent results were observed in 64% of patients). Soft tissue transport is a feasible method in providing good soft tissue coverage on the bone ends. Although it has no advantages over microvascular techniques, it might be an good alternative in the absence of an experienced flap surgeon. Nonetheless, high-quality controlled studies are needed to assess its long-term safety and efficacy.

Software simulations of changing offsets and thus soft tissue tension when revising anatomic to reverse total shoulder arthroplasty in convertible platform systems.

Revision shoulder arthroplasty may involve the need to remove a well-fixed humeral stem. To avoid this, convertible platform systems have been introduced. The biomechanics of reverse total shoulder arthroplasty (rTSA) differs from anatomic shoulder arthroplasty (aTSA). The different humeral osteotomy and soft tissue tension may jeopardize the optimal results of the converted rTSA. The aim was to evaluate the radiographic parameters of soft tissue distraction when converting an aTSA to rTSA in a platform system and assess the capability of conversion without "over-stuffing" the shoulder in the "best-case scenario". Radiographic analysis of soft tissue distraction parameters: difference in acromio-humeral distance, difference in lateral humeral offset and difference in latero-inferior displacement were evaluated in aTSA and in the converted rTSA in six different implants. Image analysing software was used on 10 non-deformed osteoarthritic shoulder X-rays to simulate conversion. The greatest increase in arm length was found for Tornier Ascend Flex (26.8 ± 3.6mm) while the smallest increase was observed with Lima SMR (19.3 ± 4mm). The humerus remained most lateralized with the Zimmer Anatomical/Inverse ( - 1.4 ± 2.9mm) while Lima SMR ( - 15.8 ± 2.7mm) was more medialized. The greatest increase in latero-inferior distance was found in the onlay systems. A group analysis of onlay rTSA showed an increase of 46% in arm length (p < 0.0001), 83% larger humeral offset (p < 0.0001) and 144% increase in latero-inferior distraction (p < 0.0001) when compared to inlay rTSA. The conversion of aTSA to rTSA using a convertible platform system may lead to significant increase in radiographic parameters corresponding to soft tissue tension. This may alter the biomechanics, restrict the convertibility or jeopardize the optimal clinical outcome of rTSA even in the best-case scenario.

Treatment of Radial Longitudinal Deficiency: An International Survey

The treatment of radial longitudinal deficiency (RLD) is highly variable without clear guidelines in the literature. The current study investigated variability among hand surgeons in treatment approaches for RLD patients with anomalies of the thumb and forearm. An online survey was distributed to 105 self-identified North American pediatric hand surgeons and 23 international pediatric hand surgeons. The survey was developed after consideration of the controversies in RLD treatment. Variations in diagnostic approach, timing of treatment, surgical indications, and surgical techniques were presented in a 21-question survey. Seventy-four (57.8%) surgeons completed the survey. For type 2 hypoplastic thumb reconstruction, 81% of surgeons prefer the flexor digitorum superficialis transfer with others using the abductor digiti minimi transfer. Ninety-four percent and 100% of surgeons favored pollicization for type 3B and type 4 hypoplastic thumb, respectively. When performing pollicization, 88% of surgeons strive for tip-to-tip pinch, with 50% preferring 100° rotation and 38% greater than 120°, compared with 12% who preferred tip-to-side pinch. Nearly half of surgeons stated they would not recommend pollicization for a patient with a stiff index finger who utilizes ulnar prehension. Ninety percent of surgeons preferred observation for a type 1 radius. Type 2 treatment preferences were highly variable, the most common response being radius lengthening. For type 3/4 radius deficiency, surgeons were divided between soft tissue release with bilobed flap and centralization (42% and 36%, respectively). If radial deviation could not be passively corrected, 63% preferred an external fixator for soft tissue distraction before centralizing. Ulnar prehension functional pattern changed treatment for 45% of surgeons in type 3/4 radius. This study provides information on areas of agreement and disagreement in the treatment of RLD. Specifically, there was consensus for treatment of types 3B and 4 thumbs and type 1 radius. Consensus was lacking for the amount of rotation in positioning of the pollicized digit, the role of pollicization with the stiff index finger, and also in the treatment of types 2, 3, or 4 radius. This study provides a framework to establish treatment guidelines for thumb hypoplasia and RLD and has identified areas lacking consensus and that require additional study.

Randomized Trial Comparing Preliminary Results of Radialization and Centralization Procedures in Bayne Types 3 and 4 Radial Longitudinal Deficiency

The choice of surgical procedure in severe (Bayne and Klug types 3 and 4) radial longitudinal deficiency (RLD) is contentious. Existing studies have reported varying results with both centralization and radialization procedures. The purpose of this study was to compare the clinical and radiologic outcome of radialization and centralization procedures at a short-to-intermediate-term follow-up for the treatment of types 3 and 4 RLD. Fourteen patients with 17 affected limbs having types 3 or 4 RLD were recruited in this prospective, randomized, controlled trial. After initial application of successive casts for soft tissue distraction, patients were randomized to 2 wrist alignment procedures-centralization and radialization. Clinical and radiologic parameters recorded at stipulated intervals until a final follow-up of 24 months included hand-forearm angle, ulnar bow, forearm length, arm length, total angulation, and range of motion at elbow, wrist, and fingers. Centralization was performed in 9 affected limbs, whereas radialization was performed in 8 affected limbs. Nine affected limbs had type 4 RLD, and 8 affected limbs had type 3 RLD. There was no significant difference in the hand-forearm angle in the immediate postoperative period. At 3 months, the radiologic hand-forearm angle increased to 19 degrees in the centralization group, while the radialization group showed an average increase to 4 degrees. This increase in the hand-forearm angle continued at 6-, 12-, and 24-month follow-up assessments. Worsening of the deformity was more in the centralization group, as compared with the radialization group. The forearm length also significantly differed in the 2 groups at 6-, 12-, and 24-month follow-up; however, when adjusted for preoperative lengths, the difference was significant only at 12- and 24-month follow-up. At a short-to-intermediate-term follow-up, radialization fares better than centralization in terms of recurrence of deformity and in terms of affecting the forearm length. Longer follow-up with a larger sample size is needed to draw definitive conclusions. Level I.

Radial club hand treated with soft-tissue distraction and subsequent pin stabilization: mid- to long-term results.

Radial club hand deformities are commonly treated with arthrolysis to allow centralization of the ulna. In this retrospective cohort study of 31 hands in 28 patients, we aimed to assess the outcomes of correction using progressive distraction and subsequent percutaneous pinning of the wrist with a corrective ulnar osteotomy. Mean follow-up time was 7 years (range 2 to 20). The angulation of the hand-forearm complex was decreased after each step of the procedure. Mean correction of the angulation was 64°, and the residual total forearm-hand angulation was 12° after completion of the surgery. At the time of bony maturity (four patients), all wrists had fused. Fifty-eight reoperations were required in 31 wrists because of pin migration or breakage, and in addition 18 secondary osteotomies of the ulna were performed. From this study we conclude that distraction and pinning provide satisfactory and stable realignment of the wrist to correct the deformity, but this treatment has drawbacks regarding the high number of reoperations and the loss of wrist mobility.Level of evidence: IV.

Optimizing the use of fibula in type II tibial hemimelia: early results.

We describe a technique for optimal use of fibula in reconstruction of type II tibial hemimelia. Six affected children with mean age of 1.4 years and treated over a 5-year period were reviewed. All underwent staged reconstruction by lowering the fibula to below knee level using Ilizarov soft tissue distraction, transfer of distal fibula under proximal tibia, and foot centralization. Mean follow-up period was 3.6 years (range: 1.6-6.05 years). Mean age at follow-up was 4.4 years, and increase in length was 4.08 cm. Tibiofibular union and foot centralization were universally achieved. Mild residual equinovarus deformity was present in three children and braced. Our technique allowed significant length gain and foot centralization in toddlers without distraction osteogenesis.

Treatment of Large Bone Defect of Long Bones: Comparison of Free Vascularized Fibular Graft with Compression-Distraction Technique

We treated 18 patients with congenital pseudarthrosis of tibia and 27 patients with acquired bone loss. Out of 18 cases of congenital pseudarthrosis of tibia the free vascularized fibular grafts (FVFGs) were performed in 16 cases and compression-distraction techniques in 2 cases. In patients with angular deformities and shortenings in the lower leg soft tissue distraction and correction were conducted. The mean soft tissue distraction period was 78.4 days, the length of bone defect 10.7 cm, the mean operative time 3.2 hours, and primary bone healing achieved in 12 cases. The mean union period was 7.3 months and the mean period of full weight bearing was 10.8 months. In 4 cases pseudarthroses and deformities developed and healed secondarily, and the treatment period ranged from 16 months to 26 months. The mean length of bone defects was 9.7 cm and the mean period of full weight bearing 14 months. The mean length of bone defects in the group of Ilizarov technique was 6.6 cm, the mean period of distraction 82 days and the mean period of full weight bearing 12.2 months. The complications include pseudarthrosis, refracture, angular deformity, equinovarus and temporary peroneal nerve palsy in the FVFG group and in the group of compression-distraction technique, refracture, equinovarus and temporary peroneal nerve palsy. The FVFG is suitable for the treatment of pseudarthrosis in young patients and the compression-distraction technique is effective option for the treatment of bone defects of patients with infection and deformity.

Early results of clubfoot management by Joshi's external stabilizing system

Introduction: With the use of Ponseti's technique, majority of children with clubfoot do not need operative treatment; however, some severe clubfoot including neglected, recurrent, and resistant forms cannot be managed by conservative methods and needs surgical intervention. The foot becomes rigid with soft tissue surgery, and bony operations can make the foot even more smaller. To avoid it, a simple alternative is to use joshi's external stabilising system (JESS) and distractor components which are used on the principle of controlled differential fractional distraction histogenesis. JESS distractors allow gradual distraction of contracted soft tissues and align all the joints of the foot so as to bring corrections of all aspects of deformity of the foot simultaneously. Purpose: To analyze the role of JESS fixator in correcting case of clubfoot in terms of cosmetic, functional, and anatomical outcome which were assessed by International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Total of 6 Clubfoot underwent differential fractional distraction in AIIMS, Raipur. Patients were assessed preoperatively for morphology and functionality and radiologically by ICFSG score. Period of correction varied from 5 to 8 weeks. Once correction is obtained, then apparatus is locked in that position for the same period and later converted to cast in plantigrade for maintenance and followed up regularly. The results were analyzed with ICFSG score. Results: Excellent to good results were obtained in all the cases which were assessed by ICFSG score. There were only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities which were neglected, resistant, and recurrent.

Management of Flexion Contractures of the Wrist by Differential Distraction

Flexion contractures of the wrist are a dreaded complication of Volkmann's ischemic contracture, postinfective/posttraumatic destruction of the wrist, or tuberculosis of the wrist joint. Most of the times, the patient is advised an amputation with prosthetic replacement as the treated limb also is like a dead limb. To avoid it, a simple alternative is to use the principle of controlled differential fractional distraction histogenesis. Joshi's external stabilization system (JESS) distractors allow gradual distraction of contracted soft tissues and align all the joints of the hand so as to bring corrections of all aspects of hand and wrist deformity simultaneously. This study was done with the aim to analyze the role of differential distraction in correcting cases of flexion contractures of the wrist in terms of cosmetic, functional, and anatomical outcome. Three flexion contractures of the wrist and hand underwent differential fractional distraction. Patients were assessed preoperatively for morphology, functionality, and radiology period of correction varied from 5 to 8 weeks. Once correction was obtained, then apparatus for differential distraction (JESS) is locked in that position for the same period and later converted to plaster cast for maintenance and followed up regularly. Excellent-to-good results were obtained in all the cases as assessed with patient-rated wrist evaluation. There were only minor complications in patients. Differential distraction by JESS frame is a simple, versatile, and cheap method suited for correcting flexion contractures of the wrist and hand, which were neglected and resistant.

Soft-Tissue Distraction Prior to Single Bone Forearm Surgery in Ulnar Longitudinal Deficiency: A Report of Two Cases

Ulnar longitudinal deficiency (ULD) is a rare congenital disease of the upper limb. The deformities caused by ULD can be very challenging and may compromise hand function during daily activities. Although the first surgical intervention dates back to the year 1952 there is still no gold standard for treating this uncommon disorder. Two children aged 16 and 3 years with ULD Bayne Type II (partial ulna aplasia) were diagnosed and treated at our department with single bone forearm surgery to achieve stability and improve function using a modified surgical method. For the purpose of an additional gain in limb length and improved cosmesis we used an Ilizarov external fixator for soft tissue distraction including radius distalization prior to the creation of the single bone forearm. This new technique and results are presented and discussed.

Skin necrosis following ilizarov application in an adolescent with radial club hand

Congenital radial club hand is a well-recognized congenital malformation of the upper extremity. It is characterized by radial deviation of the hand and shortening of the forearm. Soft-tissue distraction with an Ilizarov fixator followed by ulnar centralization in a staged approach for the Type IV radial club hand is well described in the literature. In this report, we describe a unique complication following Ilizarov application for soft-tissue distraction in a patient with Type IV radial club hand. A longitudinal skin necrosis appeared at the radial side of the forearm and hand that healed spontaneously after the cessation of distraction.

Correction of "Wrist" Deformity in Radial Dysplasia: A Systematic Review and Meta-Analysis.

Background:Radial dysplasia affects 1 in 6,000 to 8,000 births, classically presenting with a shortened, bowed ulna and radially deviated hand. The optimal treatment remains unclear, with several opposing approaches advocated. This review aims to clarify the long-term outcomes of nonsurgical and surgical treatment of the “wrist” deformity.Methods:The Embase, MEDLINE, PubMed, Cochrane Central, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (ICTRP) databases were searched for published and unpublished studies reporting long-term outcomes of surgical or nonsurgical treatment of children with radial dysplasia. Results were not restricted by date or language. Primary outcomes were hand-forearm angle, ulnar length, and “wrist” active range of motion (ROM). Studies were assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. Data for the change in hand-forearm angle were pooled using random-effects meta-analysis, and mean differences and 95% confidence intervals were obtained. Primary outcome data at last follow-up were pooled, and means and standard deviations were obtained. The PROSPERO registration of this study was CRD42016036665.Results:Of 104 studies identified, 12 were included in this review. Five were retrospective cohort studies and 7 were case series. No randomized studies were found. Study quality was low or very low according to the GRADE criteria. The hand-forearm angle of nonsurgically treated patients worsened during childhood, from 66° to 84°, whereas “wrist” active ROM, at 61°, was better than that for most surgically treated patients. Ulnar length with nonsurgical treatment was predicted to be 64% of normal, but was not directly reported. Isolated soft-tissue release provided a modest reduction in hand-forearm angle compared with nonsurgical treatment. Soft-tissue distraction with centralization or radialization achieved the best hand-forearm angle correction (16° radial deviation). Radialization maintained better “wrist” active ROM (46°) and ulnar length than centralization. Microvascular second metatarsophalangeal joint transfer yielded better reported “wrist” active ROM (83°) and good ulnar length compared with other surgical techniques, but a slightly worse hand-forearm angle (28°).Conclusions:There was low-quality evidence that soft-tissue distraction plus centralization or radialization achieved the best correction of the hand-forearm angle for children with radial dysplasia.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Current Concepts in Radial Club Hand.

Radial club hand is a complex congenital abnormality of the radial or pre-axial border of the upper extremity. It has a wide range of phenotypes from hypoplasia of the thumb to complete absence of the radius and the first ray. Centralization with tendon transfer is a popular method for maintaining the correct position of radial club hand. On the other hand, various corrections were devised, e.g. radialization after distraction to emphasize the fact that the head of the ulna is positioned under the radial carpal bones and is no longer placed in a slot in the center of the carpus, microvascular epiphysis transfer, gradual correction using Ilizarov method, for Bayne Type III or Type IV. We should pay attention to the recurrence of radial deformity or circulatory impairment with the tension. Lunate excision or ulnar shortening can be selected for tension-free correction. Radialization can be indicated for avoiding the recurrence of radial flexion. However, we should pay attention of the radial protrusion of the ulnar head. For avoiding the recurrence of radial deformity or circulatory impairment, gradual correction using Ilizarov external fixation can be indicated, especially in the cases with severe radial deviation or with short forearm. In the mild cases, Bayne Type I or Type II, radius lengthening is accompanied by a soft-tissue distraction or release at the ulnar carpal joint with keeping wrist and forearm motion without producing growth plate damage.

Management of congenital radial club hand by gradual correction

Introduction Severe congenital radial club hand is aesthetically unacceptable. This paper represents our experience in treating early and late diagnosed cases using gradual distraction by Ilizarov external fixator. Methods We treated 34 cases of congenital radial club hand with an age ranged from 1 to 15 years. There were 20 girls and eight bilateral cases. Three had been treated on both sides. So, we have treated 37 limbs. Nine cases had been operated before. Centralization alone was done in 12 cases and followed by lengthening in eight cases. Ulnar lengthening and gradual correction of wrist deformities were done for the rest of cases. The patients were followed clinically and radiographically with the following parameters: hand forearm angle, range of motion, daily functional activities, extent of lengthening achieved, and cosmetic improvement. Results The follow up ranged from 1 to 10 years. The magnitude of lengthening achieved ranged from 5 to 11 cm. The average healing index was 52.02 days/cm with cosmetic appearance satisfaction in all cases. Complications included; pin tract infection in 24 cases, flexion contractures of the elbow and fingers in 26 cases [which mostly disappeared during follow up], and spontaneous ulnocarpal fusion in 2 cases. Two cases suffered fracture in the regenerate zone. Conclusions The use of the Ilizarov method with gradual distraction of bone and soft tissues in treatment of radial club hand was effective in forearm lengthening with functional and cosmetic improvement.